The sick liver patient
etiologies
- existing liver disease? Acute vs chronic liver failure
- drugs
- alcohol
- viral infections
- sepsizzzz
- etc:
- HELLP
- vascular
- metabolic, Wilson's disease
- autoimmune
- ...sometimes idiopathic
- toxins: amanita
king's college criteria
- pH < 7.3 or INR > 6.5 (PT > 100s)
- Cr > 300micromol/L
- grade III or IV encephalopathy
management strategies
airway
- if their consciousness level is so low, then RSI may be the only way forward
breathing
- potential hazards: pulmonary aspiration; Pleural effusion
circulation
- hyperdynamic circulation
- inotropes if required - norad
- albumin?
disability
- avoid sedatives if possible
- go for drugs that do not require hepatic metabolism - remi vs fent
- short half lives are your friend - propofol
- see hepatic encephalopathy in acute liver failure
- opposite pathology compared to alcohol withdrawal
- risk of cerebral oedema (compared to the Decompensated cirrhosis patients)
exposure
fluids
- electrolyte management → prevent ascites
- co-existing renal failure - depending on etiology, or as part of hepatorenal syndrome
gastro
- Risk hypoglycaemia
- thiamine needs to be given with glucose
- Optimise Nutrition in ICU - 35-40kcal/kg/day?
haem
- potential hazards: Upper GI bleed